High frequency of neurosyphilis in HIV-positive patients diagnosed with early syphilis

BACKGROUND

Syphilis is an infection frequently seen with HIV, and European guidelines on the management of syphilis suggest that HIV-infected patients may have an increased risk of early neurological involvement, sometimes asymptomatic. Recent study shows a relationship between neurosyphilis and cerebrospinal fluid (CSF) HIV viral load (VL), which in turn may be associated with subsequent neurocognitive decline.

OBJECTIVES AND METHODS

The aim of the study was estimation of the frequency of neurosyphilis among HIV-positive patients with early syphilis. The study included all patients diagnosed with early syphilis who had lumbar puncture performed in the years 2008-2012. Analysis included CSF parameters (serology, mononuclear cells, protein, glucose, chloride and lactate levels), CD4 count, serum VL and highly active antiretroviral therapy (HAART). Diagnosis of neurosyphilis was confirmed by CSF serology [positive fluorescent treponemal antibody and/or Venereal Disease Research Laboratory (VDRL) test(s)] and increased number of mononuclear cells. Statistical analysis included χ(2) tests with an accepted significance level of P < 0.05.

RESULTS

Lumbar puncture was performed in 72 patients, all men, with median age 33 (interquartile range 11) years. Neurosyphilis was confirmed in 65 (90.28%) of the patients. No statistically significant association between CSF parameters and CD4 count was found. However, statistically significant associations were found only between pleocytosis and serum VL > 1000 HIV-1 RNA copies/mL (P = 0.0451), as well as HAART treatment (P = 0.0328). The proportion of confirmed neurosyphilis cases, also in patients with low serum VDRL titres, was very high.

CONCLUSIONS

Considering the high proportion of patients who objected to having LP performed in the absence of neurological symptoms and the risk associated with this procedure, it may be preferable to use treatments with good CNS penetration in all HIV-positive patients with early syphilis.

Demographic and HIV-specific characteristics of participants enrolled in the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial

OBJECTIVES

The risks and benefits of initiating antiretroviral treatment (ART) at high CD4 cell counts have not been reliably quantified. The Strategic Timing of AntiRetroviral Treatment (START) study is a randomized international clinical trial that compares immediate with deferred initiation of ART for HIV-positive individuals with CD4 cell counts above 500 cells/μL. We describe the demographics, HIV-specific characteristics and medical history of this cohort.

METHODS

Data collected at baseline include demographics, HIV-specific laboratory values, prior medical diagnoses and concomitant medications. Baseline characteristics were compared by geographical region, gender and age.

RESULTS

START enrolled 4685 HIV-positive participants from 215 sites in 35 countries. The median age is 36 years [interquartile range (IQR) 29-44 years], 27% are female, and 45% self-identify as white, 30% as black, 14% as Latino/Hispanic, 8% as Asian and 3% as other. The route of HIV acquisition is reported as men who have sex with men in 55% of participants, heterosexual sex in 38%, injecting drug use in 1% and other/unknown in 5%. Median time since HIV diagnosis is 1.0 year (IQR 0.4-3.0 years) and the median CD4 cell count and HIV RNA values at study entry are 651 cells/μL (IQR 584-765 cells/μL) and 12,754 HIV RNA copies/mL (IQR 3014-43,607 copies/mL), respectively.

CONCLUSIONS

START has enrolled a diverse group of ART-naïve individuals with high CD4 cell counts who are comparable to the HIV-positive population from the regions in which they were enrolled. The information collected with this robust study design will provide a database with which to evaluate the risks and benefits of early ART use for many important outcomes.

Quality of Life in Patients Treated with First-Line Antiretroviral Therapy Containing Nevirapine And/Or Efavirenz

Objective

To assess whether differences in safety profiles between nevirapine (NVP) and efavirenz (EFV), as observed in the 2NN study, translated into differences in ‘health related quality of life’ (HRQoL).

Design

A sub-study of the 2NN study, with antiretro-viral-naive patients randomly allocated to NVP (once or twice daily), EFV or NVP+EFV, in addition to stavudine and lamivudine.

Methods

Comparing differences in changes of HRQoL over 48 weeks as measured with the Medical Outcomes Study HIV Health Survey (MOS-HIV) questionnaire, using analysis of variance.

Results

The 2NN study enrolled 1216 patients. No validated questionnaires were available for 244 patients, and 55 patients had no HRQoL data at all, leaving 917 patients eligible for this sub-study. A total of 471 (51%) had HRQoL measurements both at baseline and week 48. The majority (69%) of patients without HRQoL measurements did, however, complete the study. The change in the physical health score (PHS) was 3.9 for NVP, 3.4 for EFV and 2.4 for NVP+EFV ( P=0.712). For the mental health score (MHS) these values were 6.1, 7.0 and 3.9, respectively ( P=0.098). A baseline plasma HIV-1 RNA concentration (pVL) ≥100 000 copies/ml and a decline in pVL (per log10) were independently associated with an increase of PHS. An increase of MHS was only associated with pVL decline. Patients experiencing an adverse event during follow-up had a comparable change in PHS but a significantly smaller change in MHS, compared with those without an adverse event.

Conclusions

First-line ART containing NVP and/or EFV leads to an improvement in HRQoL. The gain in HRQoL was similar for NVP and EFV, but slightly lower for the combination of these drugs.

High prevalence of genotypic resistance to nucleoside reverse transcriptase inhibitors among therapy-naive individuals from the Warsaw cohort

BACKGROUND

The purpose of this study was to recognize nucleoside reverse transcriptase inhibitor (NRTI)-resistant HIV-1 strains among a group of therapy-naive patients, and subsequently to guide the choice of antiretroviral therapy.

PATIENTS AND METHODS

HIV strains present in sera of 128 antiretroviral therapy-naive patients were tested for NRTI resistance-associated mutations. The RT-PCR amplified HIV rt regions were analyzed with an INNI-LiPA-HIV-1 RT assay. The number and pattern of resistance-associated mutated codons were determined and interpreted as resistance to particular drugs.

RESULTS

Mutated codons were detected in 66 (51.5%) out of 128 tested samples. In 54 (81.8%) out of 66 samples, a K70R mutation was identified, which was followed by an M184V mutation in 22 cases (33.3%). For a majority of these samples, mixed wild/mutant populations were recognized in 44 (66.6%) cases. The interpretation of hybridization data revealed drug-resistant strains in 37 (28.9%) out of all samples tested. The determined resistance to particular drugs was as follows: 20 strains were resistant to zidovudine (ZDV), ten to lamivudine (3TC) and six to didanosine (ddI)/zalcitabine (ddC)/abacavir (ABC). In one case, a ZDV/3TC-resistant HIV strain was found.

CONCLUSION

The prevalence of mutations associated with NRTI resistance was high in the tested cohort. The key reasons for that were most probably needle and drug sharing within the group of intravenous drug users (IVDUs) and the use of ZDV in monotherapeutic regimes in the early 1990s.

[Initial assessment of the use of polymerase chain reaction (PCR) in diagnosis of tuberculosis among patients of the Center for Diagnosis and Treatment of AIDS]

This initial report on the use of PCR in diagnosis of TB was based on a group of 180 patients observed in the AIDS Diagnosis and Therapy Center in Warsaw. Out of 6 patients with positive results of PCR assay for MTB, five had positive AFB smears in induced sputum or BAL, two had positive MTB cultures. Five of them were treated with tuberculostatic drugs with clinical improvement and had negative sputum PCR MTB results after several weeks. Additional 11 patients with AFB positive sputum or BAL smears and negative PCR MTB were observed. None of them developed pulmonary tuberculosis, and none of them was confirmed by culture as MTB infection. The results presented in this paper confirm high specificity and sensitivity of polymerase chain reaction (PCR) as an fast diagnostic test very useful in the clinical settings of AIDS. With the increase of collected material further evaluation will be continued.

[Initial evaluation of the diagnostic usefulness of tuberculin tests among the patients of the Center of Diagnosis and Treatment of AIDS]

Tuberculin and Candida skin tests were done on 98 HIV(+) and 42 control HIV(-) patients of AIDS Diagnosis and Therapy Center in Warsaw. Prevalence of the positive Tuberculin tests in the control group was 29% and it was not significantly different from those groups of patients HIV(+) whose CD4 cell count was higher than 350. For those with CD4 cell count 350 or below, tests were positive only in two cases both of the patients with active tuberculosis. The prevalence of positive Candida tests was in the control group only 12% and such result did not differ significantly from any other group of HIV positive patients with different CD4 cell counts. It is concluded that routine Tuberculin skin tests might be of value due to low initial prevalence among patients of the AIDS Center and that those persons who undergo conversion into positive tests will be under high suspicion of TB asymptomatic infection. Low prevalence and rather random distribution of positive Candida skin tests shows their insufficiency as single reference tests in anergy panel.